- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $309.03 / $691.83
| Facility | | $112.20 | $309.03 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $288.40 / $338.84
| Professional | | $204.17 | $288.40 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $891.25 / $891.25
| Professional | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $676.08 / $1,096.48
| Facility | | $295.12 | $676.08 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $288.40 / $288.40
| Professional | | $87.10 | $288.40 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $354.81 / $467.74
| Facility | | $263.03 | $354.81 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $1,412.54 / $1,412.54
| Professional | | $467.74 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $2,511.89 / $2,511.89
| Professional | | $1,548.82 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $309.03 / $562.34
| Facility | | $173.78 | $309.03 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $288.40 / $338.84
| Professional | | $245.47 | $288.40 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $309.03 / $562.34
| Facility | | $190.55 | $309.03 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $501.19 / $1,445.44
| Professional | | $63.10 | $501.19 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $741.31 / $1,479.11
| Facility | | $112.20 | $741.31 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $323.59 / $588.84
| Professional | | $257.04 | $323.59 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $302.00 / $380.19
| Professional | | $302.00 | $302.00 | $380.19 |